Electronic Health Records, Autocoding, and Ewe: Don’t Be a Sheep!
Many electronic health record programs may make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. There is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.
Practice Points
- Know when to bill for evaluation and management (E&M) services performed on the same visit as a dermatologic procedure.
- Consult documentation guidelines from the Centers for Medicare & Medicaid Services when making coding decisions about E&M services.
- Watch that your electronic health record program is not overcoding.
Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).
Final Thoughts
In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!
